Provider Demographics
NPI:1275420903
Name:LEWIS, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8516 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-5131
Mailing Address - Country:US
Mailing Address - Phone:651-270-5718
Mailing Address - Fax:
Practice Address - Street 1:2551 N CLARK ST STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7725
Practice Address - Country:US
Practice Address - Phone:651-470-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD007539133V00000X
MN5465133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered